J Thorac Cardiovasc Surg 2001;121:S32-S34
© 2001 The American Association for Thoracic Surgery
Developing the Academic Surgeon: A Symposium |
Influencing the political process for cardiothoracic surgeons
Timothy J. Gardner, MD
From the University of Pennsylvania Health System, Philadelphia, Pa.
Address for reprints: Timothy J. Gardner, MD, Division of Cardiothoracic Surgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA 19104 (E-mail: gardnert{at}uphs.upenn.edu).
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Abstract
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Medicare was established by congressional legislation to provide excellent health care for all older US citizens. The economic viability of Medicare is in question, however, and the possibility of reduced services or program curtailments has been raised. To ensure appropriate support for our professional goals, as thoracic surgeons we must articulate our professional needs and expectations for continued medical progress.
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Introduction
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The availability and provision of health care is a responsibility taken on completely by government or, at the least, overseen by government on behalf of its citizens. In developed countries, including the United States, Canada, and the countries of Europe, national governments underwrite or guarantee health care delivery in varying degrees. In the United States, with a population of more than 225 million persons, Medicare is the only truly nationalized health care program in our society. Although only about 40 million Americans are direct participants in Medicare and as such have most of their health care provided through Medicare funding, this single national health care program has an enormous and growing impact on how health care is provided in this country.
The Medicare program is funded directly by the federal government. It has become an expected entitlement for all American citizens older than 65 years and for many of those with chronic illnesses. Because the rules and conditions are dictated by congressional action and laws, Medicare coverage of beneficiaries functions within the realm of political activity. In a broader sense, health policy for all citizens is determined by legislative action and the programmatic initiatives of the federal government. Because so many important details of our health care delivery system depend on decisions made within government, it is mandatory that we understand the government processes that influence issues such as access to specialty care, support for technological development, support for graduate medical education and resident training, and so on.
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Nature of the challenge
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Although many physicians in organized medicine objected to nationalized health care delivery, Medicare was initiated by the federal government in 1965 in an attempt to respond to perceived limitations in the health care provided for older Americans. The program has been extremely successful in ensuring complete health care for all older citizens. Access to cardiothoracic surgical care has been assured and has grown steadily over the 35 years that Medicare has been in existence. Medicare, however, was established in the context of the population dynamics, economic factors, and financial projections the 1960s. The striking growth of the elderly segment of the population, all of whom at 65 years of age qualify for full Medicare coverage, has markedly altered the annual cost of the program. Extensive advances in medical and related technology, including general adoption of surgical and other invasive treatment of older citizens for advanced heart disease, thoracic cancer, and advanced vascular disease, among other illnesses, have caused substantial funding shortfalls and an impending financial crisis for Medicare.
In response to these funding challenges, the US Congress, through direct legislative action, and the Health Care Financing Administration (HCFA), through administrative and program management policies, have implemented a number of changes in the Medicare program. Among the most important changes has been the establishment of prospective payment for hospitalization of Medicare patients. In this system, payment is based on the nature of the medical illness or condition through use of the so-called diagnosis-related group method. Physician reimbursement also has been substantially reformed with a system intended to base physician payment on a relative value scale of physician work and practice expense.
1 Other HCFA policies have resulted in limitations on the introduction or support for new therapies and technologies. The most obvious change experienced by most thoracic surgeons over the past decade has been reduced reimbursement for professional services. Hospitals have been under pressure to improve the efficiency and overall quality of medical care which is provided in the hospital, and there may be some reluctance to offer complex care to very elderly patients.
With the aging portion of the population steadily increasing and with our medical capabilities continuing to expand dramatically, there is concern for the Medicare program in its present form. It has been widely expressed by persons in all areas of the health policy community that substantial changes in Medicare coverage must be considered. An increasingly important influence on our overall national health care system has been adoption of Medicare guidelines and policies by other providers and insurers of health care programs. Formulas such as the resource based relative value method for physician reimbursement, defined prospective payments by diagnosis-related group, and the lack of approval of so-called experimental therapies dominate almost all health care programs. The public policy and philosophical underpinnings of the Medicare program, that is, that provision of the same level of health care in the same manner to all citizens is a patient's moral or legal right, has been accepted as a definitive tenet of US society. Medicare policies prohibit practices such as balance billing and private care of Medicare participants. No stratification of type or style of care is allowed, not even that which is acceptable within the British National Health System. Medicare participation by patient and provider is more strictly regulated than any other social program in the United States including support for public education. There is no practical way to choose not to use Medicare and "go private."
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The importance of engagement
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The desires and expectations of the public for health care delivery, like its expectation for public safety, educational opportunities, and other essential quality-of-life issues, become the public policy of the nation. The expectations of the public are derived from historical and cultural factors, which are influenced by sociologists and health policy experts and become translated into government policies through congressional legislation. Once a program such as Medicare is established, a government agency, in this case, HCFA, administers the program with considerable executive discretion but within the confines of the enabling legislation. The public has two opportunities to influence health policy. The first is in the legislative phase by influencing the election and general responsiveness of lawmakers. The second is at the executive or administrative level by petitioning and influencing HCFA, the agency responsible for administration of Medicare. Political philosophy frequently reflects a specific agenda of the executive branch. For example, HCFA, in a Republican presidential administration, may be more inclined to one set of programmatic biases than it would be if directed by an appointee of a Democratic president.
Legislation, especially on an issue that affects the entire population, such as health care, rarely is formulated along strictly political party lines. The influence of a Republican as opposed to a Democratic administration may have little substantial influence on HCFA rule-making and program adjudications. What may be more important from the perspective of specialty groups, such as thoracic surgeons, is to have the interest and understanding of congressional legislators, health care and public policy experts, and executive branch administrators regarding the nature and needs of thoracic surgical care. Advances in therapeutic capabilities, which may be imperceptible to the public, can be overlooked by members of Congress and even by health policy experts. With a cacophony of agendas and interest groups, including competing medical groups and physicians vying for attention, the needs and accomplishments of highly skilled specialists such as ourselves may not be well appreciated.
Thoracic surgeons and other advanced medical specialists have been less well represented in the health policy community in Washington than have primary care groups. With Medicare funds and other features of the heath care system being fought over by the diverse spectrum of medical interest groups, we have not been seen or heard with sufficient effectiveness.
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Strategies for the future
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Despite the clear importance of our specific specialty work to the health and welfare of our fellow citizens, and despite the importance of cardiac and thoracic health to improved longevity and quality of life, the priority of needs for our specialty must be better understood within the public sphere. We will have little effect on health policy unless we are "at the table" and unless our goals, aspirations, expectations, and promises to society are articulated and understood. 2 Our specialty is small in number. We have to struggle for attention and recognition, especially within large medical institutions such as the American Medical Association, which is dominated by the numerically influential primary care groups. We are losing the art of coalition building for effective political action because we prefer and are accustomed to functioning autonomously.
To be effective in influencing the political process to ensure support for our work, we must be well informed on the issues involved. We must understand the complex rules of Medicare and be engaged in public policy debates over Medicare reform and how to provide health insurance for all Americans. We must support our specialty's organizations, both national and regional. Some of us must participate in related professional organizations, such as the American Medical Association, the American College of Surgeons, and the American College of Cardiology, to be part of specific coalitions, which can exert enhanced influence in the public policy area. We must avoid damaging polarization, as has occurred in the past in the American Medical Association because of undue influence of some groups and the exclusion and ultimate withdrawal of others.
With respect to the political process itself, we should take advantage of the respect and social standing we are given by fellow citizens. Some of us should become spokespersons and leaders in our communities. Busy clinicians, including most thoracic surgeons, have been absent from the grass roots citizen forums that are the foundation for policy formulation and political activity in this country. Some thoracic surgeons must be involved in local, state, and national politics, as supporters, advisors, or even participants. We must accept the need to actively and financially support candidates for political office who understand the nature of our mission. We should support politicians who can be expected to foster access to specialty care and biomedical research, support for technological developments, and health coverage for all citizens. In this context, we must be willing to prioritize our political goals to ensure the success of those who will represent our goals in government. The presence of a thoracic surgeon in the US senate, for example, in the person of Senator Bill Frist, has been important in ensuring that health care issues are addressed properly in a legislative environment composed of non-physicians. Personal disagreement with Frist's political positions in other areas should not limit our support for his continued service in the senate.
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Summary
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For thoracic surgeons to influence the political process, we must be well informed and involved in our communities. Effective involvement entails more than simply relying on our professional skills and dedication. What is needed is a sophisticated understanding of how public expectations and opinions affect health policy, what the current political challenges are to ensure progress in our health care system, and how health policy and delivery translate into reality. Effective involvement requires participation of thoracic surgeons at all levels of public discourse, from local medical society and community activities to elective national office. Although thoracic surgeons and physicians in general may never lose their positions of importance in society, support for our work and for continued advancement in specialty care will be determined in large measure by a complex but responsive political process.
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Footnotes
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Read on April 29, 2000, at the Eightieth Annual Meeting of The American Association for Thoracic Surgery, Toronto, Ontario, Canada. 
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References
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- Gardner TJ. The Medicare program and thoracic surgery: crisis or opportunity? Ann Thorac Surg 1998;65:905-8.[Free Full Text]
- Gardner TJ. The Medicare program and thoracic surgery: challenges for the new century. Ann Thorac Surg 2000;69:1312-4.[Free Full Text]
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Abstract
Introduction
